Osteoporosis

Section I: Evidence Summary

Definitions

Osteoporosis: In children, the diagnosis of osteoporosis is based on two criteria: i) the presence of low Bone Mineral Density (BMD) defined as a z-score less than -2.0 on a DXA* scan, and ii) the presence of a significant fracture history (long-bone fracture of the lower extremities, vertebral compression fracture, or two or more long-bone fractures of the upper extremities). *Dual Energy X-ray Absorptiometry (DXA) Scan: Measures bone mineral content per unit of area. In children it is important that results are compared to pediatric reference data and reported as z scores adjusted for the child’s age, sex and height.

Why is Osteoporosis Important?

Individuals with a physical disability such as cerebral palsy (CP) are at risk for fragility fractures (osteoporosis) secondary to osteopenia from decreased weight-bearing. Other risk factors often co-exist including poor nutrition with decreased calcium and vitamin D intake, vitamin D deficiency from decreased exposure to sunlight and medications that lower bone density (e.g. some anticonvulsants).

Osteopenia paired with trauma (e.g. falls) can lead to painful fragility fractures. Individuals with CP who are non-ambulatory have a 20% chance of having a fragility fracture. Frequently these involve the shaft of the longbones such as the distal femur.

Target Population: Children/youth with CP who are nonambulatory and at risk for or have osteoporosis

Prevention Strategies

Three prevention strategies are recommended:

Nutrition and Calcium (Ca): Review the child’s growth charts and assess for decreasing weight velocity and/or low body mass index and if present provide nutritional counselling. Complete a dietary history to estimate Ca intake (see section 3 for dietary Ca food reference chart) and check that intake is in the recommended range for age (700 mg elemental Ca for 1 to 3 years of age, 1000 mg for 4 to 8 years of age, and 1300 mg for 9 to 18 years of age). If dietary Ca intake is low, provide dietary counselling to increase Ca through the diet (the dietary route is preferred to avoid constipation caused by supplemental Ca).

Vitamin D2/D3 (VitD) Supplementation: Vitamin D is important for healthy bones and can be low in individuals who have poor nutritional intake or decreased exposure to sunlight. Supplement with regular VitD2/3 (800-1000 international units per day) if the individual lives in a northern climate or has decreased sun exposure as the non-hydroxylated version is very safe. If possible check 25-OH vitamin D levels at baseline and then repeat after 6 months to ensure that the individual is in the ‘normal’ range.

Fragility Fracture Treatment

If an individual with CP has a fragility fracture order additional investigations.These can include bloodwork (Ca, Phosphate, Parathyroid Hormone), an X-ray of the fracturesite, and a DXA scan to determine bone mineral density. Ensure adequate nutrition, Ca and Vit D status. Bisphosphonates should also be considered in children although the long-term safety on growing bones is unknown. Bisphosphonates help to build bone density by suppressing bone resorption. Consultation with a bone specialist is recommended. In children, bisphosphonates are typically given intravenously three to four times per year rather than orally.

UVA Child Development and Rehabilitation Center
Professor of Pediatrics, University of Virginia

Richmond, VA

Developmental Pediatrician

Deborah Gaebler-Spira, MD

Rehabilitation Institute of Chicago
Professor of Pediatrics and PM&R, Northwestern Feinberg School of Medicine

Chicago, IL

Physiatrist

Blythe Dalziel, PT

Holland Bloorview Kids Rehabilitation Hospital

Toronto, Canada

Physiotherapist

Feedback/Comments

The American Academy for Cerebral Palsy and Developmental Medicine has developed care pathways to assist the busy clinician. Please submit any advice or constructive feedback to make this pathway more useful.

NOTE: Feedback will be directed to the AACPDM Care Pathway Taskforce to review and consider on a queue 6-month basis.

Mission & Vision

Mission
To provide multidisciplinary scientific education for health professionals and promote excellence in research and services for the benefit of people with and at risk for cerebral palsy and other childhood-onset disabilities.

Vision
AACPDM is a global leader in the multidisciplinary scientific education of health professionals and researchers dedicated to the well being of people with and at risk for cerebral palsy and other childhood-onset disabilities.